Author Topic: Acupuncture for low back pain  (Read 1510 times)

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Offline HanEyeAm

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Re: Acupuncture for low back pain
« Reply #15 on: February 18, 2017, 05:29:17 PM »
IIRC Dr. Novella stresses that the placebo effect is technically any noted effect outside of the testing branch of a study, and that the more tightly-controlled the study, the more placebo effects tend to disappear. Do I have this right?

"Placebo effect/response" is defined a dozen ways, most broadly as an effect of a treatment that would not be expected to have an effect. Unfortunately, the term loses utility when it is that broad.

The best placebo is a completely inert pill or procedure under conditions that completely eliminate any possible differences between conditions. Patient is masked, research team is masked, treatment is completely indistinguishable from the treatment, and the treatment is completely inert. If the placebo meets those conditions (and whether the treatment is inert needs skeptical consideration) the only explanation for effects of placebo are patient expectancies and procedural factors (e.g., kindness of the staff), which will have equivalent effects on subjects in treatment and in placebo groups. Put another way, the key to isolating the effect of a treatment (sans expectancies and procedures) is to control all aspects except the active treatment and inert comparator (placebo).

A significant difficulty of conducting clinical trials using behavioral/procefural interventions is that (1) the patient and/or interventionist cannot be masked because (2) the procedure or method of delivery is different from the actual treatment. Take for instance sham acupuncture. The interventionist knows what treatment is being given so may inadvertently give off signals to the patient. Also, the patient may be aware that the needles or placement are non-standard. At some point the "placebo" is different enough from the treatment that it becomes an active intervention. But where is that point?

Stumbled across this super article yesterday. It has it all: placebo research, accupuncture, and Skeptical Inquirer.

http://harvardmagazine.com/2013/01/the-placebo-phenomenon
« Last Edit: February 18, 2017, 05:41:06 PM by HanEyeAm »

Offline HanEyeAm

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Re: Acupuncture for low back pain
« Reply #16 on: February 18, 2017, 05:40:09 PM »
The thing which sealed acupuncture's coffin for me was the finding that sticking the needles in the wrong places was exactly as effective as sticking them in the right places.

Doesn't that make you curious about what is making it effective?

It is a gigantic leap to claim there is something effective about the intervention.

I refer you to the meta-analyses above. Acupuncture can be effective, whether we understand the mechanism or not.

I refer you to the meta-analyses above.

From the abstract of the first one:

Quote
Acupuncture appears effective for AMCI when used as an alternative or adjunctive treatment; however, caution must be exercised given the low methodological quality of included trials. Further, more rigorously designed studies are needed.

From the abstract of the second one:

Quote
Our review provided low-quality evidence that real acupuncture has a moderate effect (approximate 12-point reduction on the 100-mm visual analogue scale) on musculoskeletal pain.

That's as far as I got with your list.

So then you got the part that it seems effective but the study quality is limited [edit: low] and more research is needed.

Many patients I have would do anything for a 12pt reduction in pain if everything else failed.
« Last Edit: February 18, 2017, 07:34:21 PM by HanEyeAm »

Offline jt512

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Re: Acupuncture for low back pain
« Reply #17 on: February 18, 2017, 06:06:43 PM »


The thing which sealed acupuncture's coffin for me was the finding that sticking the needles in the wrong places was exactly as effective as sticking them in the right places.

Doesn't that make you curious about what is making it effective?

It is a gigantic leap to claim there is something effective about the intervention.

I refer you to the meta-analyses above. Acupuncture can be effective, whether we understand the mechanism or not.

I refer you to the meta-analyses above.

From the abstract of the first one:

Quote
Acupuncture appears effective for AMCI when used as an alternative or adjunctive treatment; however, caution must be exercised given the low methodological quality of included trials. Further, more rigorously designed studies are needed.

From the abstract of the second one:

Quote
Our review provided low-quality evidence that real acupuncture has a moderate effect (approximate 12-point reduction on the 100-mm visual analogue scale) on musculoskeletal pain.

That's as far as I got with your list.

So then you got the part that it seems effective but the study quality is limited and more research is needed.

Many patients I have would do anything for a 12pt reduction in pain if everything else failed.

I got to the part where they said the evidence was low quality.

Offline HanEyeAm

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Re: Acupuncture for low back pain
« Reply #18 on: February 18, 2017, 07:45:30 PM »




The thing which sealed acupuncture's coffin for me was the finding that sticking the needles in the wrong places was exactly as effective as sticking them in the right places.

Doesn't that make you curious about what is making it effective?

It is a gigantic leap to claim there is something effective about the intervention.

I refer you to the meta-analyses above. Acupuncture can be effective, whether we understand the mechanism or not.

I refer you to the meta-analyses above.

From the abstract of the first one:

Quote
Acupuncture appears effective for AMCI when used as an alternative or adjunctive treatment; however, caution must be exercised given the low methodological quality of included trials. Further, more rigorously designed studies are needed.

From the abstract of the second one:

Quote
Our review provided low-quality evidence that real acupuncture has a moderate effect (approximate 12-point reduction on the 100-mm visual analogue scale) on musculoskeletal pain.

That's as far as I got with your list.

So then you got the part that it seems effective but the study quality is limited and more research is needed.

Many patients I have would do anything for a 12pt reduction in pain if everything else failed.

I got to the part where they said the evidence was low quality.

Got it. You read that existing studies, as a whole, have low quality, and stop reading. I think you could offer more useful comments as a (bio?) statistician, but ok.

Offline jt512

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Re: Acupuncture for low back pain
« Reply #19 on: February 18, 2017, 07:51:30 PM »
Got it. You read that existing studies, as a whole, have low quality, and stop reading.

Yeah.

Quote
I think you could offer more useful comments as a (bio?) statistician, but ok.

To be more specific, I'd have to read the low-quality studies.  But there's not much point.  The results can't be relied on.

Offline HanEyeAm

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Re: Acupuncture for low back pain
« Reply #20 on: February 18, 2017, 08:55:51 PM »
Got it. You read that existing studies, as a whole, have low quality, and stop reading.

Yeah.

Quote
I think you could offer more useful comments as a (bio?) statistician, but ok.

To be more specific, I'd have to read the low-quality studies.  But there's not much point.  The results can't be relied on.

I don't blame you at all for not wanting to read them. If you change your mind, the Nature one is actually pretty good, IMO. It really gets into the details, discusses how the findings relate to relatively recent standards for acupuncture research, etc.

Offline arthwollipot

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Re: Acupuncture for low back pain
« Reply #21 on: February 19, 2017, 04:59:56 AM »
Got it. You read that existing studies, as a whole, have low quality, and stop reading.

Yeah.

Quote
I think you could offer more useful comments as a (bio?) statistician, but ok.

To be more specific, I'd have to read the low-quality studies.  But there's not much point.  The results can't be relied on.

I don't blame you at all for not wanting to read them. If you change your mind, the Nature one is actually pretty good, IMO. It really gets into the details, discusses how the findings relate to relatively recent standards for acupuncture research, etc.

...and concludes that the evidence is poor.

Offline HanEyeAm

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Re: Acupuncture for low back pain
« Reply #22 on: February 19, 2017, 11:37:44 AM »
Got it. You read that existing studies, as a whole, have low quality, and stop reading.

Yeah.

Quote
I think you could offer more useful comments as a (bio?) statistician, but ok.

To be more specific, I'd have to read the low-quality studies.  But there's not much point.  The results can't be relied on.

I don't blame you at all for not wanting to read them. If you change your mind, the Nature one is actually pretty good, IMO. It really gets into the details, discusses how the findings relate to relatively recent standards for acupuncture research, etc.

...and concludes that the evidence is poor.

No, it concludes the quality of evidence is low.

I don't think it is appreciated that "low quality evidence" is still evidence. The Reports article outlines the definitions for evidence if you are interested (cf PRISMA for more info). It doesn't mean no evidence. And it suggest to me, at least, that more research is warranted, improving the study quality at each stage.

Evidence-based medicine is consulting the evidence base, clinical judgement, and patient choice. Sometimes a treatment of "low evidence" with a moderate effect is the best option. At least, the ACP thinks so. Do you think they would be so easily fooled by foo or political mischief?
« Last Edit: February 19, 2017, 03:23:24 PM by HanEyeAm »

Offline Crash

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Re: Acupuncture for low back pain
« Reply #23 on: February 19, 2017, 01:03:24 PM »

I don't think it is appreciated that "low quality evidence" is still evidence. The Reports article outlines the definitions for evidence if you are interested (cf PRISMA for more info). It doesn't mean no evidence. And it suggest to me, at least, that more research is warranted, improving the study quality at each stage.

Evidence-based medicine is consulting the evidence base, clinical judgement, and patient choice. Sometimes "low evidence" of a moderate effect is the best option. At least, the ACP thinks so. Do you think they would be so easily fooled by foo or political mischief?

  Low quality evidence is all there is.  The proponents of acupuncture always trot out the argument that there is not enough research because in spite of massive volume, none of it verifies their wondrous claims for acupuncture.  The fact is the research is overwhelming and more would just be beating the proverbial dead horse.  Like a lot of things people believe, acupuncture is a contrivance that sounds plausible to a few gullible victims.  The origins of acupuncture are ambiguous but with any common sense it appears to be just some made up shit.  First you have to assume that chi is a thing and that acupoints have meaning.  That's a big stretch.  I want strong evidence and not some testimonial like proponents seem to prefer. 

Offline arthwollipot

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Re: Acupuncture for low back pain
« Reply #24 on: February 20, 2017, 01:44:41 AM »
Got it. You read that existing studies, as a whole, have low quality, and stop reading.

Yeah.

Quote
I think you could offer more useful comments as a (bio?) statistician, but ok.

To be more specific, I'd have to read the low-quality studies.  But there's not much point.  The results can't be relied on.

I don't blame you at all for not wanting to read them. If you change your mind, the Nature one is actually pretty good, IMO. It really gets into the details, discusses how the findings relate to relatively recent standards for acupuncture research, etc.

...and concludes that the evidence is poor.

No, it concludes the quality of evidence is low.

I don't think it is appreciated that "low quality evidence" is still evidence. The Reports article outlines the definitions for evidence if you are interested (cf PRISMA for more info). It doesn't mean no evidence. And it suggest to me, at least, that more research is warranted, improving the study quality at each stage.

Evidence-based medicine is consulting the evidence base, clinical judgement, and patient choice. Sometimes a treatment of "low evidence" with a moderate effect is the best option. At least, the ACP thinks so. Do you think they would be so easily fooled by foo or political mischief?

I think that drawing a distinction between "poor evidence" and "low quality evidence" brings us to an entirely new level of hair-splitting that has been heretofore unknown in human endeavour.

Offline jt512

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Re: Acupuncture for low back pain
« Reply #25 on: February 20, 2017, 02:08:33 AM »
I think that drawing a distinction between "poor evidence" and "low quality evidence" brings us to an entirely new level of hair-splitting that has been heretofore unknown in human endeavour.

Which one, if either, is actually supposed to be worse?

Offline arthwollipot

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Re: Acupuncture for low back pain
« Reply #26 on: February 20, 2017, 02:11:34 AM »
I think that drawing a distinction between "poor evidence" and "low quality evidence" brings us to an entirely new level of hair-splitting that has been heretofore unknown in human endeavour.

Which one, if either, is actually supposed to be worse?

No idea. They both mean that the evidence is crap.

Offline Fast Eddie B

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Re: Acupuncture for low back pain
« Reply #27 on: February 20, 2017, 09:24:51 AM »
If nothing else, the distinction is certainly pendantic!
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Offline HanEyeAm

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Re: Acupuncture for low back pain
« Reply #28 on: February 20, 2017, 01:17:58 PM »
Got it. You read that existing studies, as a whole, have low quality, and stop reading.

Yeah.

Quote
I think you could offer more useful comments as a (bio?) statistician, but ok.

To be more specific, I'd have to read the low-quality studies.  But there's not much point.  The results can't be relied on.

I don't blame you at all for not wanting to read them. If you change your mind, the Nature one is actually pretty good, IMO. It really gets into the details, discusses how the findings relate to relatively recent standards for acupuncture research, etc.

...and concludes that the evidence is poor.

No, it concludes the quality of evidence is low.

I don't think it is appreciated that "low quality evidence" is still evidence. The Reports article outlines the definitions for evidence if you are interested (cf PRISMA for more info). It doesn't mean no evidence. And it suggest to me, at least, that more research is warranted, improving the study quality at each stage.

Evidence-based medicine is consulting the evidence base, clinical judgement, and patient choice. Sometimes a treatment of "low evidence" with a moderate effect is the best option. At least, the ACP thinks so. Do you think they would be so easily fooled by foo or political mischief?

I think that drawing a distinction between "poor evidence" and "low quality evidence" brings us to an entirely new level of hair-splitting that has been heretofore unknown in human endeavour.

The difference between levels of evidence is absolutely hair-splitting. To a degree that is normal in science. Very specific (operational) definitions are essential in good quality research and in understanding our world.

As mentioned above, "low quality evidence" is operationally defined to a meticulous degree in the articles and various standards like PRISMA. Although studies (and standards) don't all use the same exact definitions, they should be well described to allow replication that is reliable. This is how good quality systematic reviews (and RCTs) are conducted and compared (and judged).

AFAIK, there is no standard operational definition for "poor evidence." It is at best a blunt, possibly misleading description and opinion. As in, "evidence for climate change is poor." See? Completely subjective and thus unassailable.
« Last Edit: February 20, 2017, 02:20:04 PM by HanEyeAm »

Offline Billzbub

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Re: Acupuncture for low back pain
« Reply #29 on: February 20, 2017, 03:03:39 PM »

I don't think it is appreciated that "low quality evidence" is still evidence. The Reports article outlines the definitions for evidence if you are interested (cf PRISMA for more info). It doesn't mean no evidence. And it suggest to me, at least, that more research is warranted, improving the study quality at each stage.

Evidence-based medicine is consulting the evidence base, clinical judgement, and patient choice. Sometimes "low evidence" of a moderate effect is the best option. At least, the ACP thinks so. Do you think they would be so easily fooled by foo or political mischief?

  Low quality evidence is all there is.  The proponents of acupuncture always trot out the argument that there is not enough research because in spite of massive volume, none of it verifies their wondrous claims for acupuncture.  The fact is the research is overwhelming and more would just be beating the proverbial dead horse.  Like a lot of things people believe, acupuncture is a contrivance that sounds plausible to a few gullible victims.  The origins of acupuncture are ambiguous but with any common sense it appears to be just some made up shit.  First you have to assume that chi is a thing and that acupoints have meaning.  That's a big stretch.  I want strong evidence and not some testimonial like proponents seem to prefer.

I see what HanEyeAm is trying to say.  Imagine if in the 1900s someone came up with the treatment of washing hands and sterilizing instruments before surgery, but they said they were removing evil spirits from their hands and tools.  Imagine further that their technique involved a lot of verbal spells and hand gestures in addition to the actual washing and sterilization.  Then, to study it, you compared the spell-casting, hand-waving version to just washing your hands and sterilizing your instruments.  You would conclude that there's no difference between the real magic ceremony and the control procedure.

To apply that to acupuncture, maybe toothpicks in random spots on your back really do make you feel better by some mechanism.  Saying that traditional acupuncture doesn't work by comparing it to sham acupuncture doesn't say that there's not some kind of mechanism, just that the woo parts of it are complete bunk.  I think HanEyeAm agrees that sham acupuncture is just as good as the woo kind, but that both may be having some kind of effect that needs more study.

I would further assume (because I'm too lazy to look) that there's already a ton of studies that show that woo and sham acupuncture are about equal to directed relaxation or massage or any other thing that involves someone chilling out while someone else pays attention to them.

So, the bottom line is that the method of acupuncture is a sham, but that it may result in decreased pain in some general way.

It would be interesting to see studies that compare all different kinds of guided relaxation to see if we can narrow down what has the best effect on what sympoms, and see if we can work out the common mechanism.